Cover Focus | Mar/Apr '18

Dr. Gatinel, the head of anterior segment and refractive surgery at the Rothschild Foundation in Paris, is a researcher and innovator with an interest in ophthalmic optics. His most recent investigative forays include taking another look at Zernike analysis to try to make it more clinically useful. In this interview, Dr. Gatinel talks about his worldly travel schedule, why he is so curious, and his love for photography.

Interviewed by Laura Straub, Editor-in-Chief, CRST/CRST Europe

BMC: Who or what drew you to ophthalmology?

Damien Gatinel, MD, PhD: I always wanted to be a doctor, but my heart was also drawn to the basic sciences, especially the hard sciences like math, physics, optics, and astronomy. It seemed logical to me that the perfect combination of these interests would be ophthalmology. When I was really young, however, I honestly thought that ophthalmology mainly dealt with optics and refractive surgery, and I had no idea that you could also do vitreoretinal procedures, for instance. Part of this perception, in France at least, is because we don’t have independent optometrists per se; instead, patients go to their ophthalmologist for refractions. There are many medical ophthalmologists who do mostly refractions and routine checks, in comparison to a few ophthalmic surgeons. Naturally, I thought ophthalmology would mainly be a specialty dealing with refractive issues—that’s essentially why I chose ophthalmology.

BMC: Once you learned more about ophthalmology, did it influence how you found your niche?

Gatinel: Long before I was a medical student, I was devouring magazines about lasers and technological inventions like that. I really believed that ophthalmology was going to be cool because I could do research in an engineering environment, work with lasers and other fancy technology, and also be a doctor. So even before I had to formally choose a medical specialty, I knew I wanted to be an ophthalmologist and I knew I wanted to do what I’m doing today in terms of refractive surgery and optics research.

In some ways, it was fortuitous that I had little appreciation of the breadth of subspecialties one can undertake as an ophthalmologist. As a result, I had a precise idea of what I wanted to do, and even when I was exposed to other specialties during my medical studies, I never deviated from this goal. I stuck with refractive surgery and issues related to ocular optics because it’s what most fascinates me.

BMC: In your research, what are you currently working on, and how is it affecting your practice and patient care?

Gatinel: Currently I’m working on a new model for more accurately describing the optical aberrations of the human eye using an approach combining mathematics and physiological optics. Second, I am also working on keratoconus detection and characterization. Third, I am working on the optical designs for the next generation of trifocal diffractive optics. Additionally, we recently published a paper on an objective cataract grading method, based on lens densitometry measurements on swept-source OCT scans with the IOLMaster 700 (Carl Zeiss Meditec).1 This method utilizes the cross-sectional image from the swept-source OCT, from which we can calculate an index of cataract opacity. This is a research project we’ve been working on for a long time—and I think it will be a very important milestone, both clinically and from a research standpoint. We’ve also undertaken some research with the HD Analyzer (Visiometrics) in the past. The idea is to define new objective measures for distinguishing between surgery for dysfunctional lens syndrome and true cataract surgery. We have experimented with other metrics in the past and now we are investigating swept-source OCT.

Last but not least, we are working on using deep learning processes and big data to improve IOL power calculations. We are just getting started with this, but we’re excited because I think we can do something great with it.

If anything, my main problem is that I have a hand in many different things all at once. It’s time consuming to be involved in so many different projects, but I don’t find myself fulfilled by just one field of study. I don’t like to stay in the same track; I like to be doing different things at the same time.

BMC: In February, you won Best Paper at the Wavefront & Presbyopic Refractive Corrections Congress in Denver for your new Zernike formula.2 Can you talk about your research and the paper that you presented?

Gatinel: This research was the core of my PhD work, which I did somewhat late in my career for various reasons. But this project was a long one. It’s aimed at providing clinicians with numbers that make more sense when they analyze ocular wavefronts. The Zernike system was designed by Frits Zernike to describe instrumental wavefront errors, such as what occurs in the optics of microscopes or telescopes, but for many reasons it’s not really suited for human eye analysis. For example, if you try to predict an eye’s refraction from the wavefront Zernike analysis, you will encounter some systematic errors. Similarly, the titration and prediction of the impact of higher-order aberrations may not be clinically as accurate.

I tried to provide a basis of functions that are more directly related to the clinical aberrations that we see in our patients. Now I’m at the stage where I’m comparing the Zernike measurements to this new class of operation—trying, for example, to see if we can predict refractions with greater accuracy. The numbers we are generating match the clinical situation more closely than the Zernike. So far, it’s been encouraging.

Of course, I was only able to undertake this work in close collaboration with mathematicians using a multidisciplinary approach. You definitely cannot work in this field alone; you need mathematicians, statisticians, and computer scientists if you really want to push things forward with any sort of momentum. I encourage my fellows to develop related skills like learning computer programming languages, which were not really required in the past in the field of medicine and ophthalmology.

BMC: What is the draw for you to attend and present at so many meetings? How do you decide which to attend?

Gatinel: I like to participate in meetings where I’m invited to speak, of course. [Laughs.] Some of them I attend so that I can learn from others, and some I attend for academic reasons. But many I go to for both reasons. I like to present on what I’m doing because I think you really need to interact with your colleagues to receive an objective external critique on what you’re doing. I also like to teach about things I believe are important. So I very much value this aspect of interaction with an audience and receiving feedback, whether positive or negative—it fuels my work and drives me with more energy and stimulus to do better. Mainly I learn from books and papers. But I do believe you need to go to meetings sometimes to be exposed to things you would never imagine or envision. When you go and listen to someone speaking about something you didn’t know about, you glean a little from what he or she says on the podium, but you also learn about what you need to develop the knowledge further—later on, on your own, to become more knowledgeable about that one thing. I would summarize this by saying that I simultaneously learn and realize what I don’t know during meetings, and later I try to fill the gaps by reading books and papers.

When I was younger, I went to many meetings like ARVO and AAO, and then I would sit and learn about what I would like to research further in greater depth. Today, I’m more often in the position of speaker, but I still like to keep my ear to the ground on what others are saying. It often gives me ideas to expand upon what they’ve done or to develop my own research based on something I find interesting.

The other aspect of these meetings is that I like to travel to countries I’m not familiar with. I love to make friends and meet colleagues in different countries. All of these things factor into my decision of whether to go to a given meeting.

BMC: What are some of your favorite places you’ve visited? And when you go somewhere new, what are the things you gravitate toward seeing and doing?

Gatinel: Definitely taking pictures and going to local museums. Museums are exciting to me for what they display, but also for the effect they provide my mindset. Being surrounded by art pieces seems to stimulate my creativity, and I always feel mentally energized after visiting an art gallery. If possible, I also attend a show, but that’s often difficult because my evenings are usually booked on business trips. But yes, when I’m not in the conference hall, if I am in a new city, I try to immerse myself in it.

In terms of landscapes, New Zealand and South Africa have left a great impression on me. I wish to explore more of the South American continent—I have been to Peru and more recently to Chile, and I was blown away by the wild beauty and variety of the Atacama desert landscapes.

I particularly like going to the United States and to Asia, my two favorite destinations. I really enjoy the US West Coast, San Francisco, for example, but I am also a big fan of New York. (There are not many meetings there, unfortunately.) With respect to Asia, I particularly adore Japan and Thailand. I appreciate the Asian hospitality and the respect they show to their visitors. Within Japan, Kyoto is a city where I could spend many weeks. Although it’s far from France and so different culturally, it sometimes feels a bit like home there, even when I’m alone. It’s hard to explain why, but I always get the same feeling when I’m there as when I’m home. I also enjoy traveling to India. It’s a fascinating country in many respects and it’s always an exciting destination for me, not to mention the fantastic photography opportunities that it offers.

I’d rather travel long distances if I can because it allows me to appreciate cultures vastly different from my own. Short trips are usually not as enticing—for a European like me, although there are many occasions to visit countries like Germany, England, Spain, and Italy, with a short professional trip, I find you have all of the stress of travel without the excitement of going somewhere new.

BMC: From your Instagram (@madeingelatin), it’s clear you enjoy taking photographs. What draws you to photography, and how does your love of photography fit together with your love of ophthalmology?

Gatinel: Ophthalmology is an exciting profession. It combines many aspects from science to medicine, discipline, and being proficient with microsurgery. But one aspect that might not come to mind at first is the artistic dimension. Photography, because it’s a visual art like painting, is something that I feel complements ophthalmology well.

If you are fascinated by optics and vision, you’re quite likely to be interested in the visual arts, and photography is made very easily accessible today with digital cameras and smartphones. I adore painting, but I must admit that I’m a self-confessed poor painter! So with photography, I try to take a picture of something I would like to paint if I could, as some sort of compensation for my lack of painting finesse. I also like playing with light. I try to take a subject that may be somewhat mundane to start with, but pay attention to the lighting and framing in particular to create something artistic with it.

I like to take pictures of luminous reflections, which form inverted images on reflective surfaces, and play with the orientation of the photo, to present it upside down. This refers to the laws of the propagation of light, which are intangible and obey universal laws, whereas our perception of the surrounding world is eminently subjective. What makes me happiest is when I take a picture of something that should be unremarkable but I am able to turn it into something interesting. It doesn’t have to be sophisticated. I take pictures every day, so what you see on Instagram is only the tip of the iceberg.

BMC: What other passions do you have outside the office?

Gatinel: I really love music, and I played piano when I was younger. I usually immerse myself in music as I work on a project. I especially enjoy classical music, from the 20th century or late 19th century, and I have a weakness for works by Ravel, Gershwin, Chopin, and Satie.

Reading is also a favorite pastime, and I prefer technical books rather than novels to keep my mind stimulated. As often as I can, I enjoy museums and art galleries as I mentioned, and I really, really, really adore old classic cars. The construction, the lines, and the aesthetics just call out to me every time.

BMC: When you retire from ophthalmology, where do you see yourself, and what do you see yourself doing?

Gatinel: I don’t think I will ever retire completely. I think I’d still read up on what people are doing and where refractive surgery is advancing. I might remain as a consultant to share my ideas with others—if I still have new ideas at that time. I have so many friends now in this field that I would relish the opportunity to travel to see them, and this would of course be related at least partially to work.

But when I’m really finished with clinics, I think I’ll travel and maybe write a book or two on things that I have to postpone for now. These would likely be technical books or something I would like to condense into a book to share with students, for example on optics made easy for clinicians. I could write, travel, see friends, and yes, probably go to more movies and shows than I can now. In terms of where I will be, I like France, but I would be interested in experiencing life for an extended period of time somewhere else, maybe in the United States or in Japan. That would be lovely.

BMC: If you had to characterize yourself in one word or phrase, what would it be, and why?

Gatinel: I would say curious. But also I love challenges. And I don’t like dogmas in my field. I hate preconceived ideas—especially things that are accepted but not really proven. I have this strong need to make my own understanding, evaluation, and objective judgment before accepting new ideas or concepts. I believe that curiosity fuels creativity.

Ultimately I think what characterizes me is my curiosity, my desire to see a little bit more or outside of what you are supposed to see, the tendency to approach things with what I call an orthogonal view. That is incorporated in my research and practice, to develop new ideas and discover new things.

BMC: If you had to nominate one creative mind in ophthalmology, whom would it be and why?

Gatinel: Gerrit Melles, MD, PhD, because of his inventiveness and creativity—he has developed many new techniques for corneal surgery. I have had the honor of meeting him on many occasions, and he has a fascinating personality. Of all the ideas he has contributed, for instance with Descemet membrane endothelial keratoplasty, he is really an innovative creator in the realm of corneal surgery.

Dr. Malyugin, Professor of Ophthalmology and Deputy Director General at the S. Fyodorov Eye Microsurgery Federal State Institution in Moscow, Russia, is an internationally recognized expert in advanced cataract and corneal surgeries. In this interview, he explains how he pioneered the Malyugin Ring, a device for pupil expansion, and shares why it’s best to keep your eyes and your mind open to the possibilities around you.

Interviewed by Laura Straub, Editor-in-Chief, CRST/CRST Europe

BMC: Who or what drew you to ophthalmology?

Boris Malyugin, MD, PhD: I’m from a medical family. My grandmother, grandfather, father, and mother are all doctors. So from the beginning, I was pretty sure that I would be a doctor. The biggest challenge for me was not the choice of whether to be a doctor, but rather which medical profession I would pursue. When I met Svyatoslav Fyodorov, MD, he was chairman of the ophthalmology department in my university. I was impressed by his lecture during the introduction to the ophthalmology course, and subsequently I was able to visit his clinic and was attracted to the specialty. You could say I was first attracted to the profession by Professor Fyodorov’s personality and, as a second step, I was attracted by ophthalmology itself.

BMC: In addition to Professor Fyodorov, who were some of your biggest influences as you were training and studying to become an ophthalmologist?

Malyugin: I should also mention Professor Zinaida Moroz. She was chief of the corneal transplant department and my mentor for many years. I spent a few years in that department at the beginning of my tenure, where I fell in love with corneal and anterior segment surgeries. Professor Moroz was my surgical mentor.

BMC: It’s been a decade since the Malyugin Ring (MicroSurgical Technology; MST) was introduced. How did you come to design the device, and what was the process you went through working with the manufacturer to make it available on a wide scale?

Malyugin: There are many things around us, and we must keep our eyes wide open to see them. The idea for the device came from the IOLs that we routinely use in the clinic. They have smooth looped haptic elements that, you might say, look more or less like the corners of a Malyugin Ring. Sometimes you catch the iris or the capsule with the haptic loop. This gave me the idea that I could use a similar mechanism or principle for other purposes.

First, I designed an IOL that can be fixated on the lens anterior capsulorrhexis. Then I came up with the idea of designing the device that is now known as the Malyugin Ring. For some time I did my best to find a partner in industry to develop the product, and one of my well-known colleagues introduced me to MST. The company proved to be a reliable partner fully committed to innovative and quality products. Larry Laks was the chief of the company at that time; we found common ground, and we began our cooperation at that point. That was, I believe, in 2006—more than 12 years ago.

BMC: Was there anything about your initial design that was changed during the process of working with MST?

Malyugin: There were several initial designs, and we carefully evaluated different models, playing with the sizes, the material, and also with the injectors and holders. A lot of engineering went into it, and a lot of artwork. MST made multiple prototypes in order to arrive at the best solution, and I tried them all. It was quite a long way between the concept and the final product you see now.

BMC: Ultimately, do you think that collaborating with the company helped to make the product stronger and better for surgical purposes?

Malyugin: I think it’s important for the innovator to find a good partner in industry. It’s a privilege, actually, to be able to achieve a successful partnership like this.

As a surgeon, you can help a certain number of people—maybe hundreds or thousands. But when you work on a technology, then this technology can become available all over the world, so you help many more people—hundreds of thousands or even millions. That is extremely rewarding. I have a very good feeling about the partnerships I have participated in.

I also have partnerships with other doctors who have their own ideas, and I enjoy trying to help them develop these ideas into products. It is important to do this for the future of our profession.

BMC: Is there anything about the device that didn’t work out the way you planned? Or are there situations where it can be used that you didn’t foresee when you first conceived it?

Malyugin: The primary challenge was finding the right material. Despite the size, the width, and the dimensions being similar, different materials can behave biomechanically in different and unpredictable manners. It was interesting for me to see how the materials acted and how we chose the right material that we ended up using in the device.

Also, it was great to witness, when other surgeons started using the device, how many of them came up with technical and innovative ideas for how to use it better and for how to modify techniques, the injection system, and so forth. It was like having this collective mind to help me improve the project and make it even better.

The input from users was valuable, and I was not expecting that aspect of creating a new product. You think that you’re doing your best on your own, but then other engaging minds make these brilliant suggestions. Also, you think of your invention as a finished product, and then you learn that there are many ways it can be further improved.

BMC: What motivates you to keep innovating surgical procedures and technologies?

Malyugin: Ophthalmic surgery itself is a challenge. It’s challenging because you deal with a certain number of routine cases, and then suddenly a routine case unexpectedly becomes an unusual case. But there is another scenario, when at the beginning of the case you see that it is going to be challenging. And, as a surgeon, you must react to the surgical environment, right?

That feeling of change and challenge engages me. It gives me the source and the motivation for innovation. I want to improve—I actually want to be able to flow with challenges, and I want to overcome them. That is a big motivator for me.

The other motivator is that I always want to do my best to help the patient. I want to do whatever is needed to make the surgery perfect. That drives me to create something to help me accomplish that. I believe this is a challenge to the profession, and it is what keeps me innovating in the surgical world to help make challenging procedures more manageable.

BMC: You are a busy person. You’re doing surgeries, keeping up with technologies, and innovating, but you’re also a medical editor or on the editorial board of several publications, including CRST Europe. How does staying involved with these publications influence your practice of ophthalmology, and what have you gained from being in these positions?

Malyugin: Our profession is advancing rapidly, so we have to keep up with the latest innovations and ideas, which are coming up all the time. So I believe that being on editorial board helps to keep up with advances in technology. This is important because there is so much that is going on, and to be a good doctor—a good surgeon—you have to be at the leading edge of progress.

Also, it is important to teach and to share your knowledge. I believe, in medicine in general and in surgery in particular, the skills transfer and peer-to-peer communication and education are very important. This is how we develop our profession, and this is how we bring up new professionals and new leaders. That is the process that should be done constantly.

Also, it’s interesting to get to know the many bright people who are in our profession. Brilliant minds like those I work with are filled with clever ideas. Sometimes you read an article and you wonder, “Why didn’t I think of that? This idea is so brilliant.” I love to read the ideas of others to help me keep up with these innovations.

BMC: What passions do you have outside the office? What is your typical day like once you’re done working?

Malyugin: Actually, I’m a workaholic—I work all the time. That’s both an unfortunate and fortunate sides of my profession. I work at home, I work at the office, I work in the laboratory. But at the same time, I never get bored with ophthalmology because I really love it.

As for the other activities, I also love to be in the countryside, to be out in nature when I’m not inside working. Swimming and mountain skiing are some of my passions. I also love hunting. This is an old tradition in Russia, and it is a way to get close to nature.

I also love to be with my children. I have 5-year-old twins, a boy and a girl, and I have another boy who is 11 months old. It’s an exciting time. I think being with family and watching the kids growing is one of the most rewarding aspects of life. The most important thing that we can do in our life is help our children to choose good vocations, to find out what kinds of personalities they have, and to give them opportunities to choose what kind of sport they like and what area or field they want to study. I’m trying to provide them with access to everything, to see what they will show an interest in, and then to give them the opportunity to be involved in those areas they would love to pursue. That’s a really interesting development that I will be enjoying in the years to come.

BMC: What is one thing you’d like to accomplish in your personal life in the next 5 years?

Malyugin: I love my profession. I love being involved in everything I am now doing. My professional field will continue to be interesting as I make and maintain contacts with people all over the world, to teach, to learn, and to innovate. These are all exciting aspects of my personal and professional life.

Regarding my personal life, I would like to find more time to be with my family, especially my kids. I regret having to take so much time away from my family due to work and travel commitments. My family is one of the passions in my life. I want my kids to be proud of me, and I want to show them the world. I want to show them how diverse the world is and provide a broad view of what is going on all over the globe. That is important. When you see the diversity of the world and of countries, the conditions under which people live and how people work, it gives you a very open mind—a bold mind. I believe that if you try to absorb the best of everything, and keep your eyes always open, you will never be tired of your life.

I’ll be happy to continue to learn from my friends and colleagues. You have to do it all your life, and that’s one of the most exciting things.

BMC: If you had to nominate one creative mind in ophthalmology, whom would it be and why?

Malyugin: This is a hard question because I know so many bright people who I admire and from whom I am still learning. To choose just one from among them is probably almost impossible. From among my US friends, I would have to mention David F. Chang, MD, whom I love very much and whose personality I admire. Robert H. Osher, MD, is another person I greatly admire. Of my European colleagues, there are also too many to choose just one. Marie-José Tassignon, MD, PhD, and Beatrice Cochener, MD, PhD, aren’t just nice women and active surgeons, but also brilliant and sharp minds.

For me, it’s hard to identify just one person. There are so many people I admire and hope to be involved with for years to come.